New Delhi: Abortion was legalised in India almost half a century ago, yet unsafe abortions--performed in unhygienic conditions by untrained providers--are the third largest cause of maternal death. Nearly 78% of the more than 15 million abortions conducted annually in India are outside of health facilities, giving rise to safety concerns. There is only one licensed provider for 224,000 women in rural areas.

India allows medical termination of a pregnancy of up to 20 weeks’ gestation to be conducted by a registered medical practitioner. There have been attempts to amend the act to expand the provider base to include nurses and non-allopathic medicine practitioners, and extend the deadline to 24 weeks from the current 20.

However, this suggestion has been facing opposition due to concerns that enlarging the provider base will facilitate sex-selective abortion, which has already dropped India’s sex ratio to 919 girls per 1,000 boys.

So, what must India do to provide safe abortion services?

Vinoj Manning, 55, executive director of Ipas Development Foundation (IDF), India, an advocacy group dedicated to preventing and managing unwanted pregnancies, tells IndiaSpend in this interview that no more than 9% of all abortions are for sex selection and India must place women’s agency, health and rights at the centre of the discussion. He says increasing awareness about safe abortions and expanding officially approved medical facilities are some of the ways to make safe abortion services more accessible.

Before joining IDF in 2002, Manning worked with Swiss Development Cooperation, a Swiss government aid organisation; PATH, a global non-profit; and the National Dairy Development Board. He has a post-graduate diploma in rural management and a MBA ‘Plus’ leadership certificate from the School of Business, Portland State University, USA.

Abortions cause 10 deaths every day--3,520 deaths a year--according to Planning Commission estimates. What can be done to make abortions safer?

Unfortunately, despite the Medical Termination of Pregnancy (MTP) Act of 1971 that was passed 47 years ago, safe abortion is still not a reality for women in India.

Lack of access to safe abortion due to the paucity of services where they are needed the most--close to their homes and communities--and shortage of legal providers is one of the core reason. Additionally, many women continue to be unaware about abortion being legal in India, and do not know where, when and how they can access safe services.

Abortion continues to be stigmatised, and there is a need for concerted efforts to normalise it in order for women to feel comfortable accessing abortion services from safe and legal providers instead of resorting to back-alley providers.

Do you have any data on the number of legal providers of abortion services in India?

There is no good exact data on the number of abortion providers in the country. Around 10 years back, we at IDF had estimated that there was only one MTP-trained doctor per 224,000 rural population. I do not estimate a dramatic change in this ratio in the last decade. The fact of the matter remains that legal abortion services are non-existent or very rare in the rural areas of India.

Abortions accounted for 3% of all non-live births in 2015--i.e., 200,000 cases according to National Family Health Survey (NFHS-4). The government estimates that 700,000 abortions are conducted per year but this 2017 Lancet study showed there were 15 million abortions in India in 2015. It also showed abortions accounted for one-third of all pregnancies with nearly half of all pregnancies being unintended. Was the government’s abortion figure an underestimate? What does the new estimate mean for access to contraception?

The government figure and the Lancet figure refer to two separate measures. The government figure of 700,000 stands for the reported number of abortions in medical facilities, while the 15 million estimate refers to the total number of abortions across the country. The Lancet study clarifies that a significant number of abortions take place outside of medical facilities.

Nevertheless, both these figures suggest an unmet need for contraception as well as the need for expanding access to abortion services.

How has implementation of the Protection of Children from Sexual Offences (POCSO) Act, 2012, affected access to abortion services in India?

These acts overlap where POCSO requires medical providers to report sexual abuse among minors and the MTP Act allows registered providers to terminate pregnancies of minors.

Providers are confused between the conflicting requirements of the two laws--the MTP Act requires them to maintain confidentiality and POCSO mandates them to report all pregnancies to the appropriate authorities as it treats all sex under 18 years of age as non-consensual.

This confusion causes delays, and sometimes leads to denial of abortion services to young girls.

Why did the health ministry withdraw the 2014 MTP amendment that would have allowed abortion up to 24 weeks?

As far as my knowledge goes, the proposed MTP amendment permitting abortions for up to 24 weeks for special category of women is still under consideration by the ministry. Often, as demonstrated in the slew of court cases in the recent past, access to abortion for survivors of rape and incest, minors, single women and other vulnerable women is delayed for various reasons.

Similarly, many foetal deformities, incompatible with life, can be determined only beyond 20 weeks. This makes it imperative that the proposed amendment to extend the gestation age be passed.

Less than a fourth of all abortions in India are provided in health facilities and the rest through misoprostol and mifepristone pills provided by chemists and informal providers under the medical method of abortion (MMA), the 2017 Lancet study said. Is it because public health facilities do not provide abortion services? Is MMA unsafe without medical supervision?

There is inadequate global or Indian evidence to determine the safety of MMA without medical supervision. While all experts agree that MMA, even without medical supervision, is far safer than the traditional invasive methods, more research is needed to establish the safety record of MMA.

The World Health Organization (WHO) recently changed the traditional way of defining abortion as either safe or unsafe. It now classifies abortion into three categories--safe, less safe and least-safe.

This disaggregation of unsafe abortion into “less safe” and “least safe” categories acknowledges the relative safety of the self-use of MMA. This is especially important in the Indian context, where it is estimated that a majority of women use MMA at home.

One of the recommendations of the Lancet study was permitting nurses, AYUSH doctors (practitioners of indigenous medicine) and trained midwives to provide abortions. Is there any attempt to do so, and if not, what reservations are holding it back?

The 2014 MTP Act amendment bill is primarily aimed at increasing the availability of safe and legal abortion services for women. One of its recommendations is to expand the provider base by permitting AYUSH providers, nurses and auxiliary nurse midwives (ANMs) to provide early abortion services after training. Such expansion of the provider base would help decentralise safe abortion care and make it more readily accessible. While newspaper reports indicate that the provision has been dropped from the proposed amendments, we are not aware of the actual situation and won’t be able to comment on this.

Despite being legal since 1971, many aspects of abortion are unknown to the general public and cause fear of prosecution among the medical community. There are also aspects about amendments to the MTP Act which are unknown. How can the discourse on abortion be separated from its sex-determination aspect?

There is a need to create more awareness. There is a need to keep abortion and sex determination separate as only 9% of abortions are undertaken for sex selection in India. Both the law enforcement and medical communities must be appraised of the need to keep abortion and gender-biased sex selection separate. It must be reiterated clearly that sex determination is a crime while abortion is legal.

In a recent case where a woman from Mumbai requested medical termination of pregnancy at 25 weeks due to marital discord, the Supreme Court said: “abortion amounts to murder”. Your comments?

The judgment by the Supreme Court denying a 20-year-old victim of domestic violence the permission to terminate her pregnancy is distressing. At a time when we are drawing attention to the need to recognise women's rights, the judgment has failed to be women-centric and progressive.

In the past, both the Supreme Court and high courts have taken progressive exceptions to the 20-week gestation legal limit imposed by law. The latest judgment negates any progress made in women's access to reproductive health and rights.

Sadly, the language used in the judgment equating abortion with murder has taken the entire debate on women's rights in India back by half a century.

In September 2017, the Supreme Court allowed a 31-week-pregnant 13-year-old rape survivor to abort, though it had previously denied a 10-year-old rape survivor from Chandigarh citing danger to her life. What should be the protocol for abortion when the mother is underage and pregnancy is a result of sexual abuse or rape?

Every case has an individual context and should be handled keeping that in mind. However, the courts should ensure that each woman is able to access her sexual and reproductive health and rights to the full. This can be achieved by keeping the woman, along with her health and right, at the centre of the discussion and the decision.

India has a 12.9% unmet need for family planning which has remained almost unchanged in a decade. Yet, this figure does not capture the unmet need for contraception among unmarried women and girls. There are also controversies related to sex education in schools. Do stigma and misinformation impact the use of contraception, leading to more abortion cases?

Yes, there are several myths and misconceptions impacting the use of contraception in our country, and this gets magnified in case of young, unmarried women. There is a need to bust these myths and misconceptions through awareness and by addressing the stigmatising notions, taboos and behaviour around contraception.

Introducing and promoting comprehensive sex education in schools is important to create awareness among the youth to empower them with knowledge about contraceptive use and safe sexual practices.

(Yadavar is a principal correspondent with IndiaSpend.)

Correction: An earlier version of the interview incorrectly said Manning worked in IPA, it has since been corrected to IDF.

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.

New Delhi: Abortion was legalised in India almost half a century ago, yet unsafe abortions--performed in unhygienic conditions by untrained providers--are the third largest cause of maternal death. Nearly 78% of the more than 15 million abortions conducted annually in India are outside of health facilities, giving rise to safety concerns. There is only one licensed provider for 224,000 women in rural areas.

India allows medical termination of a pregnancy of up to 20 weeks’ gestation to be conducted by a registered medical practitioner. There have been attempts to amend the act to expand the provider base to include nurses and non-allopathic medicine practitioners, and extend the deadline to 24 weeks from the current 20.

However, this suggestion has been facing opposition due to concerns that enlarging the provider base will facilitate sex-selective abortion, which has already dropped India’s sex ratio to 919 girls per 1,000 boys.

So, what must India do to provide safe abortion services?

Vinoj Manning, 55, executive director of Ipas Development Foundation (IDF), India, an advocacy group dedicated to preventing and managing unwanted pregnancies, tells IndiaSpend in this interview that no more than 9% of all abortions are for sex selection and India must place women’s agency, health and rights at the centre of the discussion. He says increasing awareness about safe abortions and expanding officially approved medical facilities are some of the ways to make safe abortion services more accessible.

Before joining IDF in 2002, Manning worked with Swiss Development Cooperation, a Swiss government aid organisation; PATH, a global non-profit; and the National Dairy Development Board. He has a post-graduate diploma in rural management and a MBA ‘Plus’ leadership certificate from the School of Business, Portland State University, USA.

Abortions cause 10 deaths every day--3,520 deaths a year--according to Planning Commission estimates. What can be done to make abortions safer?

Unfortunately, despite the Medical Termination of Pregnancy (MTP) Act of 1971 that was passed 47 years ago, safe abortion is still not a reality for women in India.

Lack of access to safe abortion due to the paucity of services where they are needed the most--close to their homes and communities--and shortage of legal providers is one of the core reason. Additionally, many women continue to be unaware about abortion being legal in India, and do not know where, when and how they can access safe services.

Abortion continues to be stigmatised, and there is a need for concerted efforts to normalise it in order for women to feel comfortable accessing abortion services from safe and legal providers instead of resorting to back-alley providers.

Do you have any data on the number of legal providers of abortion services in India?

There is no good exact data on the number of abortion providers in the country. Around 10 years back, we at IDF had estimated that there was only one MTP-trained doctor per 224,000 rural population. I do not estimate a dramatic change in this ratio in the last decade. The fact of the matter remains that legal abortion services are non-existent or very rare in the rural areas of India.

Abortions accounted for 3% of all non-live births in 2015--i.e., 200,000 cases according to National Family Health Survey (NFHS-4). The government estimates that 700,000 abortions are conducted per year but this 2017 Lancet study showed there were 15 million abortions in India in 2015. It also showed abortions accounted for one-third of all pregnancies with nearly half of all pregnancies being unintended. Was the government’s abortion figure an underestimate? What does the new estimate mean for access to contraception?

The government figure and the Lancet figure refer to two separate measures. The government figure of 700,000 stands for the reported number of abortions in medical facilities, while the 15 million estimate refers to the total number of abortions across the country. The Lancet study clarifies that a significant number of abortions take place outside of medical facilities.

Nevertheless, both these figures suggest an unmet need for contraception as well as the need for expanding access to abortion services.

How has implementation of the Protection of Children from Sexual Offences (POCSO) Act, 2012, affected access to abortion services in India?

These acts overlap where POCSO requires medical providers to report sexual abuse among minors and the MTP Act allows registered providers to terminate pregnancies of minors.

Providers are confused between the conflicting requirements of the two laws--the MTP Act requires them to maintain confidentiality and POCSO mandates them to report all pregnancies to the appropriate authorities as it treats all sex under 18 years of age as non-consensual.

This confusion causes delays, and sometimes leads to denial of abortion services to young girls.

Why did the health ministry withdraw the 2014 MTP amendment that would have allowed abortion up to 24 weeks?

As far as my knowledge goes, the proposed MTP amendment permitting abortions for up to 24 weeks for special category of women is still under consideration by the ministry. Often, as demonstrated in the slew of court cases in the recent past, access to abortion for survivors of rape and incest, minors, single women and other vulnerable women is delayed for various reasons.

Similarly, many foetal deformities, incompatible with life, can be determined only beyond 20 weeks. This makes it imperative that the proposed amendment to extend the gestation age be passed.

Less than a fourth of all abortions in India are provided in health facilities and the rest through misoprostol and mifepristone pills provided by chemists and informal providers under the medical method of abortion (MMA), the 2017 Lancet study said. Is it because public health facilities do not provide abortion services? Is MMA unsafe without medical supervision?

There is inadequate global or Indian evidence to determine the safety of MMA without medical supervision. While all experts agree that MMA, even without medical supervision, is far safer than the traditional invasive methods, more research is needed to establish the safety record of MMA.

The World Health Organization (WHO) recently changed the traditional way of defining abortion as either safe or unsafe. It now classifies abortion into three categories--safe, less safe and least-safe.

This disaggregation of unsafe abortion into “less safe” and “least safe” categories acknowledges the relative safety of the self-use of MMA. This is especially important in the Indian context, where it is estimated that a majority of women use MMA at home.

One of the recommendations of the Lancet study was permitting nurses, AYUSH doctors (practitioners of indigenous medicine) and trained midwives to provide abortions. Is there any attempt to do so, and if not, what reservations are holding it back?

The 2014 MTP Act amendment bill is primarily aimed at increasing the availability of safe and legal abortion services for women. One of its recommendations is to expand the provider base by permitting AYUSH providers, nurses and auxiliary nurse midwives (ANMs) to provide early abortion services after training. Such expansion of the provider base would help decentralise safe abortion care and make it more readily accessible. While newspaper reports indicate that the provision has been dropped from the proposed amendments, we are not aware of the actual situation and won’t be able to comment on this.

Despite being legal since 1971, many aspects of abortion are unknown to the general public and cause fear of prosecution among the medical community. There are also aspects about amendments to the MTP Act which are unknown. How can the discourse on abortion be separated from its sex-determination aspect?

There is a need to create more awareness. There is a need to keep abortion and sex determination separate as only 9% of abortions are undertaken for sex selection in India. Both the law enforcement and medical communities must be appraised of the need to keep abortion and gender-biased sex selection separate. It must be reiterated clearly that sex determination is a crime while abortion is legal.

In a recent case where a woman from Mumbai requested medical termination of pregnancy at 25 weeks due to marital discord, the Supreme Court said: “abortion amounts to murder”. Your comments?

The judgment by the Supreme Court denying a 20-year-old victim of domestic violence the permission to terminate her pregnancy is distressing. At a time when we are drawing attention to the need to recognise women's rights, the judgment has failed to be women-centric and progressive.

In the past, both the Supreme Court and high courts have taken progressive exceptions to the 20-week gestation legal limit imposed by law. The latest judgment negates any progress made in women's access to reproductive health and rights.

Sadly, the language used in the judgment equating abortion with murder has taken the entire debate on women's rights in India back by half a century.

In September 2017, the Supreme Court allowed a 31-week-pregnant 13-year-old rape survivor to abort, though it had previously denied a 10-year-old rape survivor from Chandigarh citing danger to her life. What should be the protocol for abortion when the mother is underage and pregnancy is a result of sexual abuse or rape?

Every case has an individual context and should be handled keeping that in mind. However, the courts should ensure that each woman is able to access her sexual and reproductive health and rights to the full. This can be achieved by keeping the woman, along with her health and right, at the centre of the discussion and the decision.

India has a 12.9% unmet need for family planning which has remained almost unchanged in a decade. Yet, this figure does not capture the unmet need for contraception among unmarried women and girls. There are also controversies related to sex education in schools. Do stigma and misinformation impact the use of contraception, leading to more abortion cases?

Yes, there are several myths and misconceptions impacting the use of contraception in our country, and this gets magnified in case of young, unmarried women. There is a need to bust these myths and misconceptions through awareness and by addressing the stigmatising notions, taboos and behaviour around contraception.

Introducing and promoting comprehensive sex education in schools is important to create awareness among the youth to empower them with knowledge about contraceptive use and safe sexual practices.

(Yadavar is a principal correspondent with IndiaSpend.)

Correction: An earlier version of the interview incorrectly said Manning worked in IPA, it has since been corrected to IDF.

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.

Swagata Yadavar
- Swagata Yadavar is a health journalist based in New Delhi. She is passionate about uncovering the gaps in access to healthcare and writing about public health policies. She has won Mumbai Press Club’s Red Ink Award for Health writing in 2014, the Laadli Media Award for Gender Sensitivity in 2013, the European School of Oncology’s 2018 Cancer Journalism Award and the American Association for Cancer Research’s 2018 June L. Bielder Prize in Cancer Journalism. She was previously with The Week, a national magazine.